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van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, Bar-Yishay I, Schoeman S, Tate DJ, Byth K, Hewett DG, Pellisé M, Hourigan LF, Moss A, Tutticci N, Bourke MJ. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70:1691-1697. [PMID: 33172927 DOI: 10.1136/gutjnl-2020-321753] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known. DESIGN Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods. RESULTS A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively. CONCLUSIONS In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.
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Shahidi N, van Hattem WA, Vosko S, Bourke MJ. Don't judge a book by its cover: except during optical evaluation. Gut 2021; 70:1252-1286. [PMID: 32220904 DOI: 10.1136/gutjnl-2020-320829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/15/2020] [Indexed: 12/08/2022]
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Sidhu M, Shahidi N, Gupta S, Desomer L, Vosko S, Arnout van Hattem W, Hourigan LF, Lee EYT, Moss A, Raftopoulos S, Heitman SJ, Williams SJ, Zanati S, Tate DJ, Burgess N, Bourke MJ. Outcomes of Thermal Ablation of the Mucosal Defect Margin After Endoscopic Mucosal Resection: A Prospective, International, Multicenter Trial of 1000 Large Nonpedunculated Colorectal Polyps. Gastroenterology 2021; 161:163-170.e3. [PMID: 33798525 DOI: 10.1053/j.gastro.2021.03.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Thermal ablation of the defect margin after endoscopic mucosal resection (EMR-T) for treating large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) has shown efficacy in a randomized trial, with a 4-fold reduction, in residual or recurrent adenoma (RRA) at first surveillance colonoscopy (SC1). The clinical effectiveness of this treatment, in the real world, remains unknown. METHODS We sought to evaluate the effectiveness of EMR-T in an international multicenter prospective trial (NCT02957058). The primary endpoint was the frequency of RRA at SC1. Detailed demographic, procedural, and outcome data were recorded. Exclusion criteria were LNPCPs involving the ileo-caecal valve, the appendiceal orifice, and circumferential LNPCPs. RESULTS During 51 months (May 2016-August 2020) 1049 LNPCPs in 1049 patients (median size, 35 mm; interquartile range, 25-45 mm; right colon location, 53.5%) were enrolled. Uniform completeness of EMR-T was achieved in 989 LNPCPs (95.4%). In this study, 755/803 (94.0%) eligible LNPCPs underwent SC1 (median time to SC1, 6 months; interquartile range, 5-7 months). For LNPCPs that underwent complete EMR-T, the frequency of RRA at SC1 was 1.4% (10/707). CONCLUSIONS In clinical practice, EMR-T is a simple, inexpensive, and highly effective auxiliary technique that is likely to significantly reduce RRA at first surveillance. It should be universally used for the management of LNPCPs after EMR. https://clinicaltrials.gov; Clinical Trial Number, NCT02957058.
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van Hattem WA, Shahidi N, Vosko S, Bar-Yishay I, Schoeman S, Sidhu M, McLeod D, Bourke MJ. Large prolapse-related lesions of the sigmoid colon. Endoscopy 2021; 53:652-657. [PMID: 32961578 DOI: 10.1055/a-1248-2175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Large prolapse-related lesions (LPRL) of the sigmoid colon have been documented histologically but may not be readily recognized endoscopically. METHODS Colonic lesions referred for endoscopic mucosal resection (EMR) were enrolled prospectively. Endoscopic features were carefully documented prior to resection. Final diagnosis was made based on established histologic criteria, including vascular congestion, hemosiderin deposition, fibromuscular hyperplasia, and crypt distortion. RESULTS Of 134 large ( ≥ 20 mm) sigmoid lesions, 12 (9.0 %) had histologic features consistent with mucosal prolapse. Distinct endoscopic features were: broad-based morphology; vascular pattern obscured by dusky hyperemia; blurred crypts of varying size and shape; and irregular spacing of sparse crypts. Focal histologic dysplasia was identified in 6 of 12 lesions (50.0 %). CONCLUSIONS LPRL of the sigmoid colon exhibit a distinct endoscopic profile. Although generally non-neoplastic, dysplasia may be present, warranting consideration of EMR.
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Shahidi N, Vosko S, Bourke MJ. Authors' response - Delineating a rectum-specific selective resection algorithm: the time is now! Gut 2021; 70:1201-1202. [PMID: 32839199 DOI: 10.1136/gutjnl-2020-322628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 12/08/2022]
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Vosko S, Gupta S, Shahidi N, Hourigan LF, van Hattem WA, Bar-Yishay I, Schoeman S, Sidhu M, Burgess NG, Lee EYT, Bourke MJ. Snare-tip soft coagulation is effective and efficient as a first-line modality for treating intraprocedural bleeding during Barrett's mucosectomy. Endoscopy 2021; 53:511-516. [PMID: 32659800 DOI: 10.1055/a-1218-6089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED BACKGROUND : Intraprocedural bleeding (IPB) during multiband mucosectomy (MBM) for Barrett's neoplasia can obscure the endoscopic field. Current hemostatic devices may affect procedure continuity and technical success. Snare-tip soft coagulation (STSC) as a first-line therapy for primary hemostasis has not previously been studied in this setting. METHODS Between January 2014 and November 2019, 191 consecutive patients underwent 292 MBM procedures for Barrett's neoplasia within a prospective observational cohort in two tertiary care centers. A standard MBM technique was performed. IPB was defined as bleeding obscuring the endoscopic field that required intervention. The primary outcome was the technical success and efficacy of STSC. RESULTS IPB occurred in 63 MBM procedures (21.6 %; 95 % confidence interval 17.3 % - 26.7 %). STSC was attempted as first-line therapy in 51 IPBs, with the remainder requiring alternate therapies because of pooling of blood. STSC achieved hemostasis in 48 cases (94.1 % by per-protocol analysis; 76.2 % by intention-to-treat analysis). No apparatus disassembly was required to perform STSC. CONCLUSIONS STSC is a safe, effective, and efficient first-line hemostatic modality for IPB during MBM for Barrett's neoplasia.
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McKay O, Shahidi N, Gupta S, van Hattem WA, El-Khoury T, Bourke MJ. Is it time to consider prophylactic appendectomy in patients with serrated polyposis syndrome undergoing surveillance? Gut 2021; 70:231-233. [PMID: 32694174 DOI: 10.1136/gutjnl-2020-321445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 12/08/2022]
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Schoeman S, Shahidi N, Bourke MJ. Snare-based full-thickness endoscopic resection for deeply invasive colorectal neoplasia. Gastrointest Endosc 2020; 92:731-734. [PMID: 32838913 DOI: 10.1016/j.gie.2020.04.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/22/2020] [Indexed: 02/08/2023]
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Gupta S, Shahidi N, Gilroy N, Rex DK, Burgess NG, Bourke MJ. Proposal for the return to routine endoscopy during the COVID-19 pandemic. Gastrointest Endosc 2020; 92:735-742. [PMID: 32360301 PMCID: PMC7187831 DOI: 10.1016/j.gie.2020.04.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
In response to the coronavirus disease 2019 (COVID-19) pandemic, many jurisdictions and gastroenterological societies around the world have suspended nonurgent endoscopy. Subject to country-specific variability, it is projected that with current mitigation measures in place, the peak incidence of active COVID-19 infections may be delayed by over 6 months. Although this aims to prevent the overburdening of healthcare systems, prolonged deferral of elective endoscopy will become unsustainable. Herein, we propose that by incorporating readily available point-of-care tests and conducting accurate clinical risk assessments, a safe and timely return to elective endoscopy is feasible. Our algorithm not only focuses on the safety of patients and healthcare workers, but also assists in rationalizing the use of invaluable resources such as personal protective equipment.
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Shahidi N, Bourke MJ. ESD, not EMR, should be the first-line therapy for early gastric neoplasia. Gut 2020; 69:1-2. [PMID: 31481547 DOI: 10.1136/gutjnl-2019-319646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
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Shahidi N, Vosko S, van Hattem WA, Sidhu M, Bourke MJ. Optical evaluation: the crux for effective management of colorectal neoplasia. Therap Adv Gastroenterol 2020; 13:1756284820922746. [PMID: 32523625 PMCID: PMC7235649 DOI: 10.1177/1756284820922746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/06/2020] [Indexed: 02/04/2023] Open
Abstract
Advances in minimally invasive tissue resection techniques now allow for the majority of early colorectal neoplasia to be managed endoscopically. To optimize their respective risk-benefit profiles, and, therefore, appropriately select between endoscopic mucosal resection, endoscopic submucosal dissection, and surgery, the endoscopist must accurately predict the risk of submucosal invasive cancer and estimate depth of invasion. Herein, we discuss the evidence and our approach for optical evaluation of large (⩾ 20 mm) colorectal laterally spreading lesions.
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Shahidi N, Sidhu M, Vosko S, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Holt B, Hourigan LF, Lee EY, Burgess NG, Bourke MJ. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69:673-680. [PMID: 31719129 DOI: 10.1136/gutjnl-2019-319785] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/17/2019] [Accepted: 10/26/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs. DESIGN EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC). RESULTS Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027). CONCLUSION EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.
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Shahidi N, Sidhu M, Bar-Yishay I, Bourke MJ. IIc or not IIc: a question for meticulous optical evaluation. Gut 2020; 69:410-512. [PMID: 31023831 DOI: 10.1136/gutjnl-2019-318616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/11/2019] [Indexed: 12/08/2022]
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Bourke MJ, Shahidi N, Heitman SJ. Endoscopic Mucosal Resection Is a Dynamic Technique: Ongoing Refinement Continues to Improve Outcomes. Clin Gastroenterol Hepatol 2020; 18:754-755. [PMID: 32063266 DOI: 10.1016/j.cgh.2019.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 02/07/2023]
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Shahidi N, Schoeman S, Bourke MJ. Acute Epigastric Pain after Gastric Endoscopic Submucosal Dissection. Gastroenterology 2020; 158:e2-e3. [PMID: 31560901 DOI: 10.1053/j.gastro.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/03/2019] [Indexed: 12/02/2022]
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Shahidi N, van Hattem WA, Bourke MJ. Just relax: allowing the endoscopist and esophagus to "cool off" between radiofrequency ablation applications affects stricture formation. Gastrointest Endosc 2020; 91:455-457. [PMID: 32036952 DOI: 10.1016/j.gie.2019.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
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Shahidi N, Rex DK, Kaltenbach T, Rastogi A, Ghalehjegh SH, Byrne MF. Use of Endoscopic Impression, Artificial Intelligence, and Pathologist Interpretation to Resolve Discrepancies Between Endoscopy and Pathology Analyses of Diminutive Colorectal Polyps. Gastroenterology 2020; 158:783-785.e1. [PMID: 31863741 DOI: 10.1053/j.gastro.2019.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/17/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
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Shahidi N, Sidhu M, Bar-Yishay I, Bourke MJ. Mind the gap: submucosal diffusion of tattoo into the resection defect. Gastrointest Endosc 2019; 90:856-858. [PMID: 31233716 DOI: 10.1016/j.gie.2019.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/17/2019] [Indexed: 02/08/2023]
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Byrne MF, Shahidi N, Rex DK. Will Computer-Aided Detection and Diagnosis Revolutionize Colonoscopy? Gastroenterology 2017; 153:1460-1464.e1. [PMID: 29100847 DOI: 10.1053/j.gastro.2017.10.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Shahidi N, Ou G, Lam E, Enns R, Telford J. When trainees reach competency in performing endoscopic ultrasound: a systematic review. Endosc Int Open 2017; 5:E239-E243. [PMID: 28367496 PMCID: PMC5370237 DOI: 10.1055/s-0043-100507] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background/Study aim The American Society for Gastrointestinal Endoscopy (ASGE) recommends that trainees complete 150 endoscopic ultrasound (EUS) procedures before assessing competency. However, this recommendation is largely based on limited evidence and expert opinion. With new evidence suggesting that this historical threshold is underestimating training requirements, we evaluated the learning curve for achieving competency in EUS. Patients/Materials and methods Two investigators independently searched MEDLINE for full-text citations assessing the learning curve for achieving competency in EUS in the period 1946 to 25 March 2016. A learning curve was defined as either a tabulated or graphic representation of competency as a function of increasing EUS experience. Results Eight studies assessing 28 trainees and 7051 EUS procedures were included. When stratifying studies based on procedural indication: three studies assessed competency in evaluating mucosal lesions, three studies assessed competency in EUS fine-needle aspiration (EUS-FNA), and two studies assessed comprehensive competency. Among studies assessing mucosal lesion T-staging accuracy, competency was achieved by 65 to 231 procedures. Among studies assessing EUS-FNA, competency was achieved by 30 to 40 procedures. Among the two studies assessing comprehensive competency in EUS, competency was not achieved in either study across all trainees. Only four of 17 trainees reached competency by 225 to 295 EUS procedures. Conclusion As EUS competency assessment has evolved to more closely reflect independent clinical practice, the number of procedures required to achieve competency has risen well above ASGE recommendations. Advanced endoscopy training programs and specialty societies need to re-assess the structure of EUS training.
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Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc 2016; 8:733-740. [PMID: 28042387 PMCID: PMC5159671 DOI: 10.4253/wjge.v8.i20.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.
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Shahidi N, Marquez Azalgara V, Yoshida E. Use of Monitoring Gamma-Glutamyl Transpeptidase Levels After Liver Transplant: A Longitudinal Retrospective Analysis of a Single-Center's Experience. EXP CLIN TRANSPLANT 2016; 14:317-322. [PMID: 27221723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Recently, gamma-glutamyl transpeptidase has garnered increased attention as a diagnostic tool in the early identification of liver disease. However, its value in liver transplant is largely unknown, as the disease processes leading to abnormal gamma-glutamyl transpeptidase levels and the expected temporal trends in gamma-glutamyl transpeptidase levels during the period after liver transplant remain unclear. MATERIALS AND METHODS Between January 2010 and August 2013, consecutive patients who underwent liver transplant at Vancouver General Hospital (Vancouver, Canada) were assessed longitudinally up to 1 year after liver transplant. A "gamma-glutamyl transpeptidase event" was defined as 2 abnormal gamma-glutamyl transpeptidase values (exceeding sex-specific limits of normal, at 55 U/L for female and 80 U/L for male patients) ≥ 1 week apart. RESULTS Our study included 147 liver transplant recipients. The median gamma-glutamyl transpeptidase level on day 1 after liver transplant was 73 U/L, which peaked to 435 U/L during the first month after liver transplant and returned to within normal parameters by 1 year. In total, there were 282 gamma-glutamyl transpeptidase events, with biliary complications (22%), acute rejection (16%), and hepatitis C virus recurrence (10%) being the most common causes. In 39% of events, no cause was identified. When attempting to identify a disease-associated event, if gamma-glutamyl transpeptidase was the initial liver biochemistry test to double in value, it had 42% sensitivity and 40% specificity. Comparatively, if gamma-glutamyl transpeptidase was the initial liver biochemistry test to become abnormal, it had 3% sensitivity and 93% specificity. CONCLUSIONS Although gamma-glutamyl transpeptidase almost universally becomes abnormal after liver transplant, a specific pathologic cause was not commonly identified. Interpreting the characteristics of gamma-glutamyl transpeptidase elevation has limited use for identifying the underlying reason for its elevation.
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Shahidi N, Bressler B, Panaccione R. The role of vedolizumab in patients with moderate-to-severe Crohn's disease and ulcerative colitis. Therap Adv Gastroenterol 2016; 9:330-8. [PMID: 27134663 PMCID: PMC4830105 DOI: 10.1177/1756283x16635081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Vedolizumab, an α4β7-integrin antagonist, is the first gut-selective monoclonal antibody that has been approved for the treatment of moderate-to-severe ulcerative colitis and Crohn's disease in many countries in the world. However, questions still remain regarding its appropriate use and placement in current treatment algorithms. Therefore, we sought out to evaluate the existing literature on the use of vedolizumab in inflammatory bowel disease. From inception to 21 June 2015 we searched MEDLINE for phase III randomized control trials assessing the utility of vedolizumab in inflammatory bowel disease, of which three were identified. The GEMINI trials demonstrate that vedolizumab is an effective and safe treatment for patients suffering from moderate-to-severe ulcerative colitis (GEMINI I) and Crohn's disease (GEMINI II and III). However, further studies are needed comparing its efficacy directly with anti-tumor necrosis factor therapies to allow for further delineation of current treatment algorithms as well as ensuring its long-term safety profile.
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Shahidi N, Ou G, Telford J, Enns R. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2016; 81:1337-42. [PMID: 25841579 DOI: 10.1016/j.gie.2014.12.054] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is an advanced endoscopic procedure that is technically more challenging and carries a higher risk of adverse events compared with standard endoscopy. A discrepancy currently exists among guidelines regarding the number of ERCPs that a trainee needs to complete before procedural competency should be assessed. Our aim was to assess the learning curve for performing ERCP. METHODS Two authors independently searched MEDLINE (1946 to November 25, 2014) along with the gray literature to identify relevant citations. To warrant inclusion, citations were required to report successful trainee cannulation rate. Successful cannulation rate, set at a value of 80% or higher, was used as our baseline reference for competency. RESULTS Nine studies, assessing 137 trainees and 17,100 ERCPs, were included in our analysis. Overall, competency was achieved among the included studies between 70 to 400 ERCPs. In the 2 studies that used pancreatic duct cannulation rate, competency was achieved by 70 to 160 ERCPs. Of the 5 studies that used selective duct cannulation rate, competency was achieved by 79 to 300 ERCPs. Finally, in the 4 studies that used common bile duct cannulation rate, 2 studies reached the reference competency threshold by 160 to 400 ERCPs. On further stratification, when assessing native papilla deep common bile duct cannulation, only 1 study reached the reference competency threshold by 350 to 400 ERCPs. CONCLUSIONS Our findings suggest that as ERCP has evolved from a predominantly diagnostic to therapeutic procedure, procedural thresholds have risen well above North American training guidelines. Therefore, advanced endoscopy training programs need to reassess their current structure to ensure that procedural competency is being reached.
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